O2 sat monitor question

[createun]

My question to the community is in regards to O2 saturation monitoring. I am a brand new nurse and have nothing to draw from except my peers.

I had a patient whose O2 level dropped signify after coming back to the room from a procedure. The monitor for O2 reads in a blue number when there is a good connection for the finger clip. In this case the monitor started to read a huge variation in the O2 stat 90-50, up and down sometimes with a loss of number and the back round was red. I moved the clip to both hands then got a et” O2 for his earlobe. Tried both lobes and his fingers again….even his toes. Tried a separate hand held machine. I also tried to use blankets to warm his extremities with blankets. I was told by more experienced nurses that the lack of pickup” was caused by his drop in temperature which went as low as 97.3. Any thought or tricks of the trade to help me keep a better O2 sat when I really needed it. It's hard to call a doctor with a situation report and not be able to give an accurate O2 level.

[JustBeachyNurse, LPN]

Warm the extremities. Use warm blankets and ensure the patient is adequately warm.

Most monitors indicate if there is a good signal or not.

Treat your patient not the number. I had patients in the 70-80% who were pink & conscious. The monitor needed new batteries and the other time the cord was microscopically damaged.

Consult with respiratory if there may be a better probe or site. Are you using a clip or an adhesive probe?

[HouTx, BSN, MSN, EdD]

Basically, pulse ox works by reflecting a concentrated beam of light on capillary circulation.. if anything cuts down cap circ, it will throw off your pulse ox. As body core temp drops, blood is shunted away from extremities toward more crucial areas of the body like the head - so that's why ear lobes are usually the second line of defense. Warming the extremity should do the trick. If not, your resp folks should have some alternatives for you that use an adhesive patch that can be put on another (warmer) body part.

[calivianya, BSN, RN]

I think your equipment must suck! 97.3 isn't low at all, it's a normal temp. It wouldn't be amiss to talk to management about the poor quality of your equipment, although I'm sure that will fall on deaf ears.

Do you have any sort of warm things? A warm blanket out of the blanket warmer, a hot pack, etc. will do a good job of warming the extremity. If that patient was very cold-natured, he might have needed actual heat and not just blankets to get his extremities warm. A good heating device in a pinch is a damp washcloth double bagged in specimen bags and microwaved for a few seconds. These can get really hot, though, so be careful.

[icuRNmaggie, BSN, RN]

Was this pt breathing effectively? Skin warm and pink or gray and cool? Alert and oriented or lethargic and confused? Low BP? Making urine?

A change in mentation along with poor perfusion as evidenced by weak peripheral pulses and loss of the Sp02 waveform could mean that this patient is in shock state. In other words, if your patient looks bad, and even if you can't put your finger on why, please call the RRT.

If you get a good pleth or signal on your finger, it's not the equipment.

[createun]

I tried both types of probes on various places. It just seemed crazy with the speed of the fluctuations.

The whole story would be to much to tell. The patient had come back from a new jet thrombosis procedure so I was concerned about a PE. The BP held semi-steady 120/80 , but the patient has a pacemaker. This went on for an hour and half. The event self rectified. I had other nurses involved and everyone seemed perplexed. To me it is so important to be able to see what the various results are going to be before they happen so you might plan accordingly as the incident unfolds.

Just thought I would throw the question out and see what others had to say, Thanks

[firstinfamily, RN]

I am glad you tried various probes and asked other nurses to check out the situation at hand. However, even though you did not have good numbers you need to look at the patient, do your assessment whenever the equipment fails you. A prudent MD is going to ask, was he in any respiratory distress, what were his lung sounds, was he exchanging good air etc. You always, always need to assess the physical symptoms of what you would expect if this pt was in distress. It looks like he did not warm up soon enough and should have had a warming blanket applied, the pulse oximeters will not work on cold extremities!!!

[nurseprnRN, BSN, RN]

Another consideration-- if the pt was NPO for all this screwing around, he's a bit on the dehydrated side. Add chilly rooms, a bit of endogenous catecholamines from fear, and you've got peripheral capillary constriction. You rehydrated him c some IVs, but those are room temp and won't warm him and actually indroduce a thermal burden as now his body has to heat them up too. Blankets won't warm him, either -- they don't add heat, they just decrease heat loss, and he's already doing a great job of that by vasoconstricting.

See what you can do to get a fluid warmer for your IV fluids, and other sources of exogenous heat. It's more comfortable but it's also better physiologically for your patients.

And do get biomedical engineering to check the machine. Sounds like it's not working well enough. Did you try it on yourself as a backup?

[MunoRN, RN]

Peripheral O2 sat monitoring requires really ideal conditions in terms of blood flow, light permeability, etc, so it's often not easily usable. With difficult to obtain readings a monitor that shows the waveform is preferable to the probes or handheld monitors. The waveform makes it easier to find a good reading and keep the reading long enough to get a reliable number. If all that fails and you really need to know their oxygenation status, then an ABG is the next option.

[JWG223]

Excellent advice to treat the patient not the number.

Pretty much all been said.

Keep the extremeties warm and correlate heart rate readings. Numbers should be relatively legit then.

[GrannyRRT]

First, learn the make and model name of your equipment. We can help you troubleshoot better. Some SpO2 monitors such as Masimo have an adjustment in the settings on a couple of models to pick up better in low perfusion states.

What was your clinical assessment of this patient? Was there a concern for altered mentation, breathing or acid base which might need intervention based on your assessment?

Core temperature and peripheral temperature can vary from each other. Specify where the temp is obtained.

Getting an ABG should not be taken lightly. It is a painful procedure. Documenting from your assessment should be done to justify doing an arterial stick. Just "MunoRN can't get a sat" without supportive assessment is poor form. The doctor whose name you used to order the ABG does not have to sign it.

Also:

The monitor is an important tool. Sometimes we have to treat by it. But, most of the time it just verifies our physical assessment.

[kool-aide, RN]

I've found that sat monitors have a hard time reading on its in afib, also. Like others have said, use your clinical assessment.